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IH

Intermountain Health Care, Inc.

Plan ID: H1994-16-0

Select Health Medicare NoRx (HMO)

2025 Select Health Medicare NoRx (HMO) H1994 — 016 — 0 is a Medicare Advantage plan . It has received a 4-out-of-5 star rating from CMS for 2025.

Learn more about Select Health Medicare NoRx (HMO) H1994 - 016 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

4 / 5 stars for 2025

$0.00 /mo

Monthly premium

$6700.00

Out-of-pocket maximum

Enroll online

Call to enroll

OR

Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2025 Select Health Medicare NoRx (HMO) H1994 — 016 — 0 is a HMO offered in Davis, Salt Lake, Utah, and Weber Counties by Intermountain Health Care, Inc.. It has a monthly premium of $0.00.

Premium Breakdown

Standard Part B Premium

$185.00

Part B premium reduction

- $0

Monthly Plan Premium

$0.00

Total Premium:

$185.00

Note:

The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.

Special needs plan type

No

Out-of-pocket maximum

$6700.00

Plan Organization:

Intermountain Health Care, Inc.

Plan Type:

HMO

Location:

Davis, Salt Lake, Utah, and Weber Counties

Drugs Covered:

No

Drug Formulary:

Pharmacies:

Pharmacies Link

Doctor Choice:

Doctors Link:

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Sign up for Select Health Medicare NoRx (HMO)

Enroll online

Call to enroll

Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

Select Health Medicare NoRx (HMO) does not provide drug coverage. If drug coverage is something you need, you should consider shopping for other plans that do provide cost sharing on drugs.

Additional Benefits

Select Health Medicare NoRx (HMO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Adjunctive General Services

In-Network: No Coins - No Co pay

Endodontics

In-Network: No Coins - No Co pay

Maxillofacial Prosthetics

In-Network: No Coins - No Co pay

Oral and Maxillofacial Surgery

In-Network: No Coins - No Co pay

Periodontics

In-Network: No Coins - No Co pay

Prosthodontics, fixed

In-Network: No Coins - No Co pay

Prosthodontics, removable

In-Network: No Coins - No Co pay

Restorative Services

In-Network: No Coins - No Co pay

Preventive dental

Dental X-Rays

In-Network: No Coins - 0.00 Copay

Oral Exams

In-Network: No Coins - 0.00 Copay

Other Diagnostic Dental Services

In-Network: No Coins - 0.00 Copay

Other Preventive Dental Services

In-Network: No Coins - 0.00 Copay

Prophylaxis (cleaning)

In-Network: No Coins - 0.00 Copay

Diagnostic procedures/lab services/imaging

Lab services

$0 copay

Diagnostic radiology services

Diagnostic tests and procedures

$0-40 copay or 0-20% coinsurance

Outpatient x-rays

$0 copay

Doctor visits

Primary

$0 copay

Specialist

$40 copay per visit

Emergency care/Urgent care

Emergency

$125 copay per visit (always covered)

Urgent care

$35 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

$40 copay

Routine foot care

$40 copay

Ground ambulance

All service types

$250 copay

Hearing

Fitting/evaluation

$0 copay

Medicare-Covered Hearing Exam

$40 copay

Hearing aids

$299-1,799 copay

Hearing aids OTC

Not covered

Inpatient hospital coverage

All service types

$400 per day for days 1 through 5 $0 per day for days 6 through 90

Outpatient hospital coverage

All service types

$40-400 copay or 20% coinsurance per visit

Optional benefits

All service types

No

Medical equipment/supplies

Prosthetics

Durable medical equipment

Diabetes supplies

$0 copay

Medicare Part B drugs

Chemotherapy

0-20% coinsurance

Other Part B drugs

0-20% coinsurance

Mental health services

Inpatient hospital - psychiatric

$400 per day for days 1 through 5 $0 per day for days 6 through 90

Outpatient group therapy visit with a psychiatrist

$15 copay

Outpatient individual therapy visit

$25 copay

Outpatient group therapy visit

$15 copay

Outpatient individual therapy visit with a psychiatrist

$25 copay

Preventive care

All service types

$0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit

$20 copay

Occupational therapy visit

$20 copay

Skilled Nursing Facility

All service types

$0 per day for days 1 through 20 $214 per day for days 21 through 55 $0 per day for days 56 through 100

Transportation

All service types

Not covered

Vision

Eyeglasses (frames and lenses)

$0 copay

Upgrades

$0 copay

Contact lenses

$0 copay

Other

$0 copay

Routine eye exam

$0 copay

Eyeglass frames

Not covered

Eyeglass lenses

Not covered

Wellness programs (eg, fitness, nursing hotline)

All service types

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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Every year, Medicare evaluates plans based on a 5-star rating system.

Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.

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Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

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